Event request form

Your name*:

Contact email*:

Contact phone:

Event date:

Event Type:

Venue:

Number of attendees expected:

Potential attendees (type of health professionals):

Type of commitment requested from the PHPN:

Will this event be:
PHPN eventCo-branded

Event overview:

Benefits the PHPN will receive:

Have you requested support/financial contribution/coordination from other organisations or networks in the region?
YesNo

If yes, please provide more information:

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